Top Ten Mental Health Parity Act Interim Rules

2010 will be an outstanding year for our mental health care system. The United States Congress passed HR 1424 — the Paul Wellstone and Pete Domenici Mental Health and Addiction Equity Act.

Known as The Parity Act, the history behind this equity model in healthcare is extensive. For many years, managed care restricted coverage when individuals sought treatment for mental health disorders. Some politicians stated that prejudicial care was based on potential increased costs and a lack of understanding of mental illnesses. Studies have demonstrated the effects of parity increase costs by 1% and the science indicating mental illness are true diseases is validated. 

The top ten Mental Health Party Act's interim rules:

  1. Single Deductible – The regulations prohibit separate cost-sharing requirements or treatment limitations that apply only to SUD or MH benefits thereby eliminating the practice of separate but equal deductibles creating the conditions for a single deductible.

  2. No Scope of Services Defined – The regulations do not define a scope of services or continuum of care for SUD or MH benefits; the regulations state that plans can define which services are covered in MH and SUD benefit packages; those definitions must be consistent with "generally recognized independent standards of current medical practice" which include the Diagnostic and Statistical Manual of Mental Disorders, the International Classification of Diseases, and State guidelines.

  3. No More EAP Gatekeeper – The regulations prohibit the EAP gatekeeper function on the basis that it is more stringent than any corresponding medical function for medical benefits.

  4. "Predominant" and "Substantially All" Defined – The rule defines the terms "predominant" and "substantially all" and gives guidance about how to determine whether financial requirements and treatment limitations imposed on SUD or MH benefits comply with the MHPAEA. The rule states that when a financial requirement or quantitative treatment limitation on a medical/surgical benefit applies to at least two-thirds of the benefits in that classification, this is considered to be "substantially all" of those benefits. A predominant level (amount) of a type of financial requirement or quantitative treatment limitation is defined as the level that applies to more than one-half of the medical/surgical benefits subject to the financial requirement or quantitative treatment limitation in that classification.

  5. Classifications of Benefits – The rule first identifies six categories of classification of benefits. These six classifications are:

      • Inpatient, in-network
      • Inpatient, out-of-network
      • Outpatient, in-network
      • Outpatient, out-of-network
      • Emergency care
      • Prescription drugs

  6. Non-Quantitative Restrictions and Limitations – The regulations include a non-exhaustive list of types of non-quantitative treatment limitations that includes:

  • Medical management standards
  • Prescription drug formulary design
  • Fail-first policies/step therapy protocols
  • Standards for provider admission to participate in a network
  • Determination of usual, customary and reasonable amounts
  • Conditioning benefits on completion of a course of treatment
  • The regulations state that the processes, strategies, evidentiary standards and other factors used to apply non-quantitative treatment limitations to SUD or MH benefits in a classification have to be comparable to and applied no more stringently than the processes, strategies, evidentiary standards and other factors used to apply to medical/surgical benefits in the same classification. The regulations acknowledge that there may be different clinical standards used in making these determinations.

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  • Co-Pays – The preamble to the rule acknowledges that some group plans have lower co-payments for PCPs than for specialists and that often SUD and MH providers are defined as specialists; the guidance makes clear that there cannot be a separate classification of generalists and specialists in determining whether certain financial requirements or treatment limitations meet the MHPAEA parity requirements.

  • Single Plan – The guidance prohibits insurers from setting up separate plans or benefit packages to try to avoid complying with the MHPAEA requirements; the guidance states that separately administered benefit packages should be considered as a single plan subject to the law and regulations.

  • Prescription Drug Formulary Design – To determine whether a group health plan/issuer is imposing unfair financial requirements on certain drugs prescribed for SUD or MH conditions, the regulations state that financial requirements imposed on drugs prescribed for the treatment of an SUD or MH condition must be compared with those imposed on other prescription drugs in the same formulary tier in which the prescription drug is classified.

  • Medicaid Guidance – The regulations acknowledge that Medicare plans offering SUD or MH services must comply with the MHPAEA but state that these regulations do not apply to those plans and that additional guidance will be given by the CMS.

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    Source: 1-800-Therapist
    Review Date: June 10, 2010
    Reviewed by: Barb Hansen BScMLT